ICD-10 Coding for Late Effects of Cerebrovascular Accident(I69.351)
Complete ICD-10-CM coding and documentation guide for Late Effects of Cerebrovascular Accident. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Late Effects of Cerebrovascular Accident
I69Primary Range
Sequelae of cerebrovascular disease
This range includes codes for residual effects following a cerebrovascular accident (CVA), such as hemiplegia, aphasia, and other neurological deficits.
Key Information: ICD-10 code for late effects of CVA
Essential facts and insights about Late Effects of Cerebrovascular Accident
Primary ICD-10-CM Code for late effects costovertebral angle
Decision Criteria
clinical Criteria
- Presence of right-sided weakness post-CVA
documentation Criteria
- Documentation of CVA date and residual deficit
Applicable To
- Right dominant hemiplegia post-stroke
Excludes
- Acute cerebrovascular accident (I60-I66)
Clinical Validation Requirements
- Neurological exam showing right-sided weakness
- Imaging confirming prior cerebral infarction
Code-Specific Risks
- Incorrectly coding acute CVA instead of sequelae
- Omitting laterality or dominance
Coding Notes
- Ensure documentation specifies the link between the deficit and the past CVA.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysphagia
R13.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.352Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Late Effects of Cerebrovascular Accident to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.351.
Impact
Clinical: Inaccurate patient records affecting care continuity., Regulatory: Potential audit flags for insufficient documentation., Financial: Delayed or denied claims due to lack of specificity.
Mitigation Strategy
Train staff on specific documentation requirements., Use templates to guide documentation.
Impact
Reimbursement: Incorrect DRG assignment leading to reimbursement issues., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data on stroke outcomes and management.
Mitigation Strategy
Use I69 codes for sequelae after the acute phase.
Impact
Inadequate documentation linking deficits to past CVA.
Mitigation Strategy
Implement comprehensive documentation templates and training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Late Effects of Cerebrovascular Accident, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Late Effects of Cerebrovascular Accident
Use these documentation templates to ensure complete and accurate documentation for Late Effects of Cerebrovascular Accident. These templates include all required elements for proper coding and billing.
Follow-up visit for post-stroke hemiplegia
Specialty: NeurologyRequired Elements
- History of Present Illness
- Physical Exam findings
- Assessment and Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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